Incivility, a term used to describe lateral violence or workplace
bullying, has been documented in the nursing literature since the
mid-1980s (Roberts, 1983). As a research construct, workplace incivility
was initially described by Andersson and Pearson in 1999 as
"low-intensity deviant behavior with ambiguous intent to harm"
(p. 456). These behaviors differ from overlap aggressive, violent,
deviant, and antisocial behaviors. According to Andersson and Pearson
(1999), incivility is differentiated from these behaviors. As depicted
in the model, if incivility is not addressed, it may spiral, resulting
in more frequent occurrences that have greater intensity. Ultimately,
there is a tipping point, where employees are at risk to be physically
and/or psychologically harmed, and the organization becomes an uncivil
entity (Kamp & Brooks, 1991).

Incivility within the profession of nursing may occur in
relationships that are irregular (patient/family/visitor), vertical
(manager to nurse or nurse to manager), unrelated (nurse to other
healthcare professional or other healthcare professional to nurse), or
horizontal (nurse to nurse) (Longo & Sherman, 2007). The terms
horizontal and lateral have been used interchangeably to describe
uncivil behaviors between peers at the same level (Longo & Sherman,
2007). While each form of incivility has specific definitions,
descriptions, and outcomes, this study focused on lateral incivility, or
incivility among nurses working in clinical settings that provide
urologic care.

The goal of this research project was to determine the presence of
workplace incivility from a peer among members of the Society of
Urologic Nurses and Associates (SUNA). This focus was selected to obtain
data useful in developing and implementing interventions specific to the
nursing population--how nurses can change the work environment for their
peers. While there is a plethora of research data describing workplace
incivility, in both clinical and academic settings, there is a paucity
of data specific to urology nurses and urologic healthcare settings.

Incivility and the Urologic Nurse

The urgency of treatment for a patient with a urologic condition
results in care being provided in clinical settings known to have high
incidences of incivility. Robinson, Jagim, and Ray (2004) posit that
stress and the acuity of patients, along with staffing issues and
burnout in clinical areas that provide critical care, result in higher
incidences of incivility. While incivility can occur in any clinical
setting, emergency departments and operative settings are at greater
risk (McNamara, 2012), a result of the urgency of care provided in these
settings.

Initially described by Spence Laschinger, Leiter, Day, and Gilin in
2009, workplace incivility was a strong predictor for job retention.
This finding has been supported through subsequent research (Leiter,
Price, & Spence Laschinger, 2010), with Generation X nurses (those
between the ages of 32 and 50 years) reporting greater negative work
environments, defined as burnout, turnover intent, physical symptoms,
supervisor incivility, and coworker and team incivility. Each variable
has been linked to retention issues. While organizational structure and
zero-tolerance policies are necessary to prevent and discipline
individuals who engage in incivility, personal knowledge is also
necessary. Lachman (2014) describes nurses, without specifying
educational preparation, as lacking skills necessary to identify and
deal with workplace incivility. These include conflict resolution and
assertiveness training (Lachman, 2014). Knowing and providing
interventions specific to peer-to-peer work environments for urologic
nurses will strengthen our profession and provide a mechanism to ensure
the care we provide remains stellar.

Purpose

The purpose of this survey design study was to allow members of
SUNA to describe their experience with respect to workplace incivility
from a peer, referred to as lateral incivility.

Methodology

Instruments

Study data included demographic data and two instruments that
assess workplace incivility from nurses employed in clinical settings.
These instruments were the Positive and Negative Affect Schedule
Short-Form (PANASSF) tool (Thompson, 2007) and the Uncivil Behavior in
Clinical Nursing Education (UBCNE) survey (Anthony, Yastik, MacDonald,
& Marshall, 2014). In addition to demographic data, each participant
was provided the opportunity to numerically (0 [not at all] to 10
[extremely satisfied]) describe job satisfaction and peer collaboration
from his or her perspective.

Demographic data. Specific demographic data were collected to
describe the study population. Urologic nursing-specific data, such as
the clinical site, educational background, and urology certification,
were also obtained. Two items--assessing job satisfaction and
satisfaction with peer collaboration--were added to the demographic data
section. These items were added to assess 'hallmark'
characteristics of nursing work environments as identified by the
American Association of Colleges of Nursing (AACN) (2002).

PANAS-SF. This 10-item mood scale allows the participant to
describe the frequency (never to always) for 5 positive and 5 negative
adjectives (Thompson, 2007). Study instructions directed the participant
to select the response that best described his or her feelings in
general. Reliability data for the PANAS-SF are similar to that reported
for the 60-item PANAS (Watson & Clark, 1994). Research, using the
PANAS-SF (Mackinnon et al., 1999), attained a reliability measured by
Cronbach alpha as 0.87. Confirmatory factor analysis attained a
two-factor model in which all items loaded to the appropriate construct
and were statistically significant. The decision to use the PANAS-SF was
made to provide brevity in data collection without loss of reliability.
Each participant describes (from never to always) how often he or she
feels the adjective used in the survey. Previous research demonstrated a
relationship between the PANAS to depression and anxiety (Crawford &
Henry, 2004). Depression, anxiety, and stress have been correlated to
staff nurse job satisfaction, satisfaction with the quality of care
provided, and job attrition (El-aal & Hassan, 2014).

Scoring responses on the PANAS-SF were performed as outlined by
Thompson (2007). Positive affect was assessed by responses on 5
adjectives (active, determined, attentive, inspired, alter). Total PANAS
scores for positive attributes were computed by summation of the alert,
inspired, determined, attentive, and active metrics; mean was computed
as total positive PANAS scores divided by 5, with higher scores
correlating to higher positivity affectivity. Negative affect was
assessed by responses on five adjectives (afraid, nervous, upset,
hostile, and ashamed). Total PANAS scores for negative attributes were
computed by summation of the upset, hostile, ashamed, nervous, and
afraid metrics; mean was computed as total negative PANAS scores divided
by 5, with higher scores correlating to higher negativity affectivity.

UBCNE. The original UBCNE was a 30-item, Likert-response survey
purported to measure incidences of incivility, specifically between
nurses, within a clinical setting. After initial testing (Anthony et
al., 2014), the survey was revised by eliminating 8 items. These items
were dropped as a result of loading highly on more than one component or
not loading on the expected component. For the purpose of this study,
items within the UBCNE survey were edited to reflect clinical scenarios
rather than clinical rotations. Thus, the UBCNE contains no reference to
student nurses and consists of 12 items that assess uncivil behavior
using a 5-point Likert-type scale. Possible responses range from 0
(never) to 4 (very often). A total incivility score can be calculated by
summing total scores; hostile/rude and exclusionary behavior subscale
scores may also be calculated. Thus, the UBCNE is capable of describing
incivility in a clinical setting and determining if the source of the
incivility is due to hostile/rude behavior or exclusionary behavior.
Inter-item reliability of the UBCNE, when administered to 106 clinical
nurses, was 0.93. Reliability of the two subscales was as follows:
hostile/rude was 0.86, and exclusionary was 0.86. Thus, the UBCNE has
demonstrated reliability in assessing incivility as the result of
hostile/rude or exclusionary behavior between nurses in clinical
settings.

Scoring responses on the UBCNE were performed as outlined by
Anthony and associates (2014). Hostile/rude behavior was assessed by
responses on 6 scenarios; exclusionary behavior was assessed by
responses on 6 scenarios. Total incivility scores were computed by
summation of all 12 UBCNE metrics; the mean incivility was total
incivility score divided by 12. The hostile behavior sum score was
computed by summation of the following metrics: being embarrassed in
front of others, rolled eyes at you, used inappropriate tone, raised
their voice, told you that you were incompetent, and refused to help
you. The exclusionary behavior sum score was computed by summation of
the following metrics: incomplete report, avoid taking report, avoid
giving report, made snide remarks, and did not involve you in patient
care. As described by Anthony and colleagues (2014), higher scores on
the UBCNE correlate to increased incidences of incivility.

Procedure

This survey design study obtained data from volunteer participants
who are nurses and members of SUNA. Participants in this study are
engaged in the profession of nursing, leaders in their organizations,
and dedicated to enhancing the workplace experience for all.

Institutional Review Board (IRB) permission to conduct the study
was secured by the Social Science IRB at the employer of the primary
investigator (PWS). In accordance with the Federal Policy for the
Protection of Human Subjects 45 CFR Part 46.101b, the study met criteria
for exempt status; thus, consent was implied upon submission of survey
responses. Data were collected using Research Electronic Data Capture
(REDCap) (Harris et al., 2009), a secure web-based research electronic
data capture software program. This software program complies with HIPAA
regulations and provides greater security than other web-based data
collection formats.

A study invitational email was sent from the SUNA National Office
to each current member of the organization. A study description, aim,
time requirement, and a link to access the study surveys were contained
within this email. If participation was desired, the individual was
instructed to click on the survey link. Once clicked, the initial item
confirmed consent for participation. From there, each survey, with
instructions detailing how to complete it, was provided.

Results

The study invitational email was sent to an estimated 2,050
individuals, which represents all SUNA members. Study inclusion criteria
were limited to presently employed registered nurses; thus, the
potential study population is unknown. In response to the email, the
study site link was opened by 664 individuals, with 207 opening the
survey. This calculates to a 31.2% study contact rate (207/664). Surveys
were completed by 173 of these individuals, indicating an 83.6%
completion, or response, rate (173/207). Thus, the study population
consisted of 173 consented, uncompensated, volunteer nurse participants
who were members of SUNA.

Frequency statistics were calculated and determined these data met
the assumptions of normalcy; thus, parametric statistics were
appropriate. Data were compared using Student's t test for
continuous variables and Chi square for categorical variables. Analyses
were conducted with SPSS Software version 24 (IBM, 2015). All tests
performed were two-tailed, and p values less than 0.05 were considered
statistically significant. Complete case analyses were performed.

Demographic characteristics. Demographically, 76.3% of these
participants (n=132) described themselves as over the age of 46 years.
The most frequent age range was 56 to 60 years (n=40; 23.1%), following
closely by 51 to 55 years (n=36; 20%), with 61 to 65 years (n=27; 15.6%)
the third most frequent category. According to AACN (2016), the average
age of a nurse is 47 years; 55% of the RN workforce is age 50 years or
older. Thus, this study population mirrors the composition of nurses.
The age distribution is displayed in Table 1.

Academically, 29.5% of these participants (n=51) identified their
highest degree earned as a bachelor of science degree in nursing (BSN).
Forty-three participants stated they have a master degree in nursing
(MSN). Combining these data with the 15 participants who report having a
doctorate in nursing (DNP) or a doctorate in philosophy in nursing (PhD)
allows a comparison of the study population to data maintained by AACN
(2011).

When combined, 58 participants, or 33.5% of the study population,
reported having an advanced degree in nursing. Ten participants reported
earning an advanced degree not in nursing (see Table 2). Reports from
AACN (2017) include only individuals with advanced degrees in nursing;
thus, individuals with advanced degrees not in nursing were excluded
from academic preparation calculations.

Multiple options allowed each participant to describe their
practice setting a variety of ways; thus, there are 194 responses to
this item. Collapsing these categories into general settings (inpatient,
outpatient/clinic, private/ specialty practice) provides an overview of
the settings in which these participants provide urologic care.
According to AACN (2016), 62.2% of all employed nurses work in a
hospital setting. Assuming the outpatient/clinic settings are adjacent
to an inpatient setting and adding these individuals to the inpatient
category result in 109 (56.1%) of the study population who work in a
hospital setting (AACN, 2016). This is still below the national average;
thus, the workplace of this study population does not reflect the
nursing workforce in general. A significant number of the study
population (43.8%) work in private practice or academic/industry
settings, which are considered non-traditional by AACN (2016). Table 3
displays practice setting descriptions.

Certification as a urologic nurse (through the Certification Board
for Urologic Nurses and Associates [CBUNA]) was reported by 67 (38.7%)
of participants; 34 (50.1%) of these individuals were also educationally
prepared at an MSN level or higher.

Within demographics, such as age category, academic preparation,
specialty, practice type, clinic type, years practicing total, and years
practicing urologic-specific, there were no significant differences (see
Table 4). Nurses not certified in urology were significantly (p=0.019)
more likely to report plans to leave their current job in the next 12
months.

Nurses who did not plan to remain in their current job for 12
months had higher total incivility scores (19.96[+ or -]10.62 versus
14.20[+ or -]9.538, p=0.005) and higher average scores (1.66[+ or -]0.88
versus 1.18[+ or -]0.79, p=0.005). Nurses who did not plan to remain in
their job for 12 months were more likely to have experienced
exclusionary and hostile behavior (10.11[+ or -]5.82 versus 7.21[+ or
-]5.24, p=0.01; 9.85[+ or -] 5.63 versus 6.99[+ or -]4.83, p=0.007),
respectively. Nurses planning to not remain in their current position
for 12 months scored lower on the PANAS positive attribute scales both
in total and on average (19.66[+ or -]3.55 versus 21.24[+ or -]2.71,
p=0.009; 3.93[+ or -]0.71 versus 4.24[+ or -] 0.54, p=0.009,
respectively), and higher on negative PANAS attribute scales in total
and on average (12.14[+ or -]4.67 versus 9.64[+ or -]3.36, p=0.001;
2.42[+ or -]0.93 versus 1.92[+ or -] 0.67, p=0.001, respectively).

Summary and Conclusion

Demographically, the study population varies from national
statistics. The highest degree earned for 31.4% of participants of this
study was reported as a BSN, while nationally, 36.8% of registered
nurses have a BSN (AACN, 2017). The Institute of Medicine (IOM) (2010)
recommends that 80% of RNs attain a BSN by 2020 and that essential
course content include identifying and addressing workplace incivility.
Thus, the decreased number of BSN-prepared nurses may contribute to the
incivility experience. Earning an advanced degree (MSN, DNP, PhD) was
reported by 33.6% of the study population. This is almost three times
the national average of 13.2% of nurses who report earning an advanced
degree (AACN, 2011). Comparing the study population to national norms
reflects a slightly lower number of BSN-prepared nurses yet a
higher-than-average number of MSN-prepared nurses. Participants in this
study were not generalist nurses, but nurses with a specific specialty.
Greggs-McQuilkin (2005) determined that individuals who are members of a
professional organization differ from non-members. Members of
professional organizations seek educational, networking, and career
assistance. In summarizing the experiences of lateral violence among
nurses with all educational preparation, the new graduate or novice
nurse is most vulnerable (Ciocco, 2017).

In an effort to describe the impact of lateral violence, subgroups
were developed based on the participant's response to remaining on
the job for the next 12 months. Comparing experiences of these two
groups provided a method of determining the effect lateral violence has
on retention.

Results from each subscale (hostility and exclusionary) of the
UBCNE were summed then compared. Participants not planning to remain in
their present position reported higher incidences of general uncivil
behaviors. While both exclusionary (p=0.01) and hostile behaviors
(p=0.007) were described as a reason, hostile behaviors had a greater
impact.

For SUNA members, incivility appears to have a statistically
significant impact on the desire to remain in one's present
position. While knowing 18.5% of SUNA members plan to change jobs in the
next 12 months may be comforting, AACN (2017) predicts a 20% shortage of
nurses by 2020. Thus, the need for urologic nurses will be as critical
as the need for any nurse. Participants in this study who are certified
as urologic nurses (n=67; 38.7%) indicated a higher-than-average desire
to remain in their present position.

Results of this study provide research evidence that can be used
when developing and implementing programs to address workplace
incivility, specifically for the urologic nurse. Mentoring and career
development programs should focus on the identification of negative
feelings and ways to prevent/minimize their effect. Anxiety and stress
have been identified as outcomes of workplace incivility; educational
offerings can provide skills necessary to cope with these feelings.
These results also describe hostile behaviors that result in workplace
incivility. Educational sessions that identify these behaviors and
provide appropriate responses are beneficial. Knowing how to properly
address inappropriate behaviors and an awareness of the organizational
policies that prevent workplace incivility would allow the nurse to
prevent further episodes of inappropriate behavior.

Workplace incivility has significant negative implications for
nurses, our patients, and healthcare organizations. Conversations and
interventions aimed at identifying and addressing incivility must occur.
Data from this study describe the scenario specific to SUNA members.
While these results may be more positive than those experienced by
general nurses or in other clinical specialty areas, we have challenges.
Providing a safe, civil workplace environment requires efforts from all
urology nurses. One effect of incivility, as reported by these
participants, is the intent to leave the present position. While job
changes occur for many reasons, these data reflect the effect incivility
has. While organizational change, policy development and implementation,
and behavioral consequences should be developed, identifying and
addressing exclusionary and hostile behaviors that occur laterally are
interventions all can provide.

Research Summary

Background

Workplace incivility, or a negative work environment, has been
linked to professional burnout, turnover intent, physical symptoms, and
patient errors. Obtaining data directly from healthcare professionals
who provide urologic care will allow workplace issues to be assessed
directly, assuring interventions developed and presented are
evidence-based.

Objective

The purpose of this survey design study was to allow members of the
Society of Urologic Nurses and Associates (SUNA) to describe their
experience with respect to workplace incivility from a peer (lateral
incivility).

Method

Data encompassed two previously validated survey instruments and
self-disclosed demographic responses. Instruments included the Positive
and Negative Affect Schedule Short-Form (PANAS-SF) and Uncivil Behavior
in Clinical Nursing Education (UBCNE) instruments and minimal
demographic data. Demographic data were used to describe the study
population and correlate responses to each instrument based on intent to
remain in the present job for the next 12 months.

Results

Data were collected from 173 SUNA members. Workplace incivility was
described by 25.3% of the study population as severe enough for them to
be planning to leave their present position within the next 12 months.
This number is higher among participants not certified in urology.

Level of Evidence--III-B

Johns Hopkins Hospital/Johns Hopkins University, 2016.

doi: 10.7257/1053-816X.2018.38.1.20

Peggy Ward-Smith, PhD, RN, is Interim Dean, School of Graduate
Studies, and Associate Professor, School of Nursing & Health
Studies, University of Missouri Kansas City, Kansas City, MO; and a
member of the Urologic Nursing Editorial Board

Jeremy Provance, MS, is a Software Analyst--Kansas City School of
Medicine, University of Missouri, Kansas City, MO.

Authors' Note: This study was supported by a grant made
available by the Society of Urologic Nurses and Associates (SuNa)
Foundation and The Allergan Foundation.

Findings of the study do not necessarily reflect the opinions of
SUNA. The views expressed herein are those of the authors, and no
official endorsement by SUNA is intended or should be inferred.

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American Association of Colleges of Nursing (AACN). (2011). The
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El-aal, N.H.A., & Hassan, N.I. (2014). Relationship between
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